paediatric urology• dilatation in pyelum et ureter • primary obstructive megaureter • second...
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Paediatric Urology
Sulya Bálint
Heim Pál Children Hospital
Department of Urology
Rare cause of childhood urinary
icontinence
• 5 years old girl
• loss of urine day- and nighttime
• physical examination
• ultrasound
• scintigraphy
• MRI
• laparoscopic nephrectomy
• in general with duplex kidney
• usually drains into the reproductive organs or urethra
• typical complain!!!
• What is paediatric urology?
– children age 0-18 years
– treating disorders of development:
• on male genito-urinary system
• on female urinary system
• useful to know embriology of genito-urinary system
– in smaller number of cases acquired disease
• Diagnostic tools:
complaints
symptoms
physical examination
laboratory examination
radiology imaging
What complaints and symptoms shall we find in
paediatric urology patient?
• abdominal, groin, scrotal, penile pain
• fever, meteorism, nausea, vomiting
• dysuria (enuresis, incontinence, stranguria,
urge, pollakisuria)
• alteration of lab. findings (purulent or/and
bloody urine, elevated CRP, PCT, serum white
cell number, creatinin, carbamid)
• atrophy/aplasia, hypotrophy/hypoplasia of
organs
• anuria, polyuria, retention of urine
Sicknesses of penis
Cellular adhesion
• physiological state!!
• spontaneous resolve
• no need lysis (forceful retraction)
Congenital phimosis
• spontaneous resolve
• topical steroid ointment
• circumcision
• earlier retrahating foreskin
• scarry, tight foreskin, stricture of urethra opening,
pseudomembrane of glans
• special type BXO (Lichen sclerosus et atrophicus)
• circumcision
Acquired/secondary phimosis
Balanitis / balanoposthitis
• inflammation of glans és foreskin
• phimosis, cell. adh.
• purulent
• local therapy with antiseptic solution
Echtyma gangraenosum
• very rare
• Pseudomonas aeruginosa sepsis
• necrosis of the skin of penis
• AB, debridément, intensive therapy
Paraphimosis
Congenital curvature of penis
• hypoplasia of corpus cavernosum
• dysplasia of fascia
• tunica albuginea
• + hypospadiasis
• operation
Hypospadiasis
Risk factors:
- endocrin
- genetic
- enviromental effect
Urethra
- from urethra plate (iu. 12 – 14 week)
- from proximal direction
- dihydrotestosteron effect
Hypospadiasis
Therapy: operation (because of functional /aesthetic/ cause
The aim of operation: 1. alignment of the penis
Hypospadiasis
Hypospadiasis
The aim of operation: 2. configuration of urethra (plastica)
Hypospadiasis
The aim of operation: 2. configuration of urethra (plastica)
Methods
• Snodgrass
• Mathieu
• Duckett
• Denis Browne
Hypospadiasis
Neourethra
• skin of penis
• foreskin
• free graft (oral mucosa, vein)
Hypospadiasis
Epispadiasis • very rare (200.000 birth/1)
• + bladder exstrophy
• abdominal wall closing
defect from umbilicus to
perineum
• etiology? (mesodermal cells
migration is not adequate)
• dorsal curvature
• anterior form
• posterior form
(incontinence)
• surgery
Epispadiasis
bladder closing in newborn age later epispadiasis (urethra) reconstruction
Priapism
• erection of penis irrespectively of sexual stimulus
• haemodinamically
ischaemiac (veno-occlusive - low-flow)
non-ischaemiac (arterial - high-flow)
• low-flow: stasis in corp. cav., pain, fibrosis - scarring, ED (haematological diseases, drugs): urgent intervention – cons. therapy – irrigation of corp. cav. (NaCl, adrenalin)
• high-flow: painless, trauma – AV fistule:
selective embolisation
Others
• trauma
• buried (trapped) penis
• virga palmata
• condyloma
• micropenis
• torsion of penis
Undescended testis (cryptorhidism)
Undescented testis (cryptorhidism)
• Undescended
testis (UDT)
The testicle is located intra-abdominally or in the inguinal canal. It is located in the
normal descent pathway and shows normal insertion of the gubernaculum.
• Cryptorchidism From the ancient Greek "kryptos" (hidden) and "orchis" (testicle). The testicle is
not palpable and is located intra-abdominally (retentio testis abdominalis) or is not
present (anorchia - aplasia).
• Ektopia testis The testicle is located beneath the skin superfascially, perineally, on the thigh or
shaft of the penis. The testicle shows abnormal insertion of the gubernaculum.
• Inguinal testicle The testicle is palpable in the groin (retentio testis inguinalis)
• Gliding testicle The testicle is located at the scrotal entrance or above the scrotum. It can be drawn
down into the scrotum, but immediately slides back into its initial position.
• Retractile
(hypermobile)
testes
The physiological retractile (hypermobile) testicle is usually present in the
scrotum or can be effortlessly pushed down into the scrotum, it retracts on
induction of the cremasteric reflex but returns spontaneously into the scrotum.
Recognizing the retractile (hypermobile) testicle is particularly important because it
does not require treatment.
•forms:
Undescented testis (cryptorhidism)
• distribution:
abdominal, inguinal, gliding testicle, aplasia: 90 %
ectopic testis: 10 %
• regulation of descent of testicle:
1. Insl3 (early, abdominal phase)
2. testosteron (late - inguinal and scrotal phase)
ectopic testicle – the left testicle is located and palpable
perineo–femoral position
Undescented testis (cryptorhidism)
Undescented testis (cryptorhidism)
• main complications: INFERTILITY
HIGHER RISK OF MALIGNANCY
• cause of infertility:
- higher temperature
- fusion anomaly between testicle and epididymis (30%)
Undescented testis (cryptorhidism)
• therapy:
- hormone?
- operation:
- orchidopexy - Shoemaker
- laparoscopia - Fowler - Stephens
- Shehata
- orchiectomy (dysgenetic testicle, after puberty)
Conclusion
The undescended testis is the most common genital
malformation in boys and should be treated before the
child’s first birthday. If medicinal therapy (LHRH and
hCG) is ineffective, orchidopexy should be performed
immediately to reduce the risk of further damage to the
testicular tissue. The boy’s parents must be informed
that correcting the cryptorchidism will facilitate future
examination of the testicle, but will not reduce the risk
of malignancy.
Undescented testis (cryptorhidism)
Severe hypospadias and undescended testis
can associate with Wilm’s tumor!
WT1 gene mutation (= Wilm’s tumor suppressor gene)
11. chromosome short arm (13. locus) (11p13).
Dilatation of upper urinary tract
• Ureteropelvic junction obstruction (UPJO)
• Ureterovesical junction obstruction (UVJO)
Ureteropelvic junction obstruction (UPJO)
• impaired urine flow from the pelvis into the
proximal ureter
• dilatation of the collecting system
• potential to damage the kidney.
• most common cause of neonatal
hydronephrosis
• incidence: 1 / 1,500
• males:females=2:1 in newborns
• IMPORTANT: antenatal and postnatal US
Ureteropelvic junction obstruction (UPJO)
• Cause
congenital obstruction
functional obstruction
high insertion of ureter
Ureteropelvic junction obstruction (UPJO)
• Cause
crossing vessels
secondary (VUR)
Ureteropelvic junction obstruction (UPJO)
• symptomps:
recurrent flank pain
abdominal pain
UTI
• diagnosis:
US
diuretic renography
MRI
(IVP)
Classification:
• Grade 0 normal (pyelon 1-5 mm)
• Grade I: pyelon dilatated (6-10 mm)
• Grade II: pyelectasia & small caliectasia (pyelon >12 mm)
• Grade III: pyelectasia & all and grand caliectasia
• Grade IV: hydronephrosis + thin parenchyma
Ureteropelvic junction obstruction
Ureteropelvic junction obstruction (UPJO)
• Therapy
in case of symptoms
decreased renal function
increased AP diameter
Grade III. – IV.
= surgery
• Technique:
Anderson – Hynes pyeloplasty : - open
- laparoscopic
ureter
dilatated pyelum
thin parenchyma
Ureteropelvic junction obstruction (UPJO)
Ureteropelvic junction obstruction (UPJO)
Ureteropelvic junction obstruction (UPJO)
Urotoday.com
Ureterovesical junction obstruction (UVJO)
• impaired urine flow from the pelvis to the UV junction
• obstructive condition of the distal ureter
• dilatation in pyelum et ureter
• primary obstructive megaureter
• second in the diff. dg. neonat. hydronephrosis
• occurs often in males and on left side
• potential to damage the kidney.
• IMPORTANT: antenatal and postnatal US
• symptomps:
recurrent flank pain
abdominal pain
UTI
• diagnosis:
US
diuretic renography
(IVP)
Ureterovesical junction obstruction (UVJO)
Ureterovesical junction obstruction (UVJO)
• therapy:
spontaneous improvement (85%)
if not = need surgery
if decreased renal function
in case of symptomps
• reimplantation methods:
Politano-Leadbetter
Cohen
Lich-Gregoir
Tóth
Kalicinsky
Ureterovesical junction obstruction (UVJO)
Vesicoureteric reflux
Grade I Reflux does not reach the renal pelvis; varying degrees of ureteral dilatation
Grade II Reflux reaches the renal pelvis; no dilatation of the collecting system;
normal fornices
Grade III Mild or moderate dilatation of the ureter, with or without kinking; moderate
dilatation of the collecting system; normal or minimally deformed fornices
Grade IV Moderate dilatation of the ureter with or without kinking; moderate dilatation
of the collecting system; blunt fornices, but impressions of the papillae still visible
Grade V Gross dilatation and kinking of the ureter, marked dilatation of the collecting
system; papillary impressions no longer visible; intraparenchymal
Vesicoureteric reflux
Diagnosis: VCUG (gold standard)
VUR grade IV. on both side VUR grade V. on right side
Vesicoureteric reflux
Diagnosis: CEUS
VUR grade IV. on both side, and in both system of right kidney
Diagnosis: - renal scan (DMSA)
- US
(- MRI)
Therapy: - resolves spontaneously
- watchful waiting
- intermittent / continuous antibiotic prophylaxis,
- bladder rehabilitation (LUTD)
Vesicoureteric reflux
Therapy - surgery
subureteric injection of bulking materials
open surgery (ureter reimplantation)
(laparoscopy and robot-assisted)
Vesicoureteric reflux
Summary of evidence
• There is no evidence that correction of persistent low-grade reflux (grades I-III)
without symptoms and normal kidneys offers a significant benefit.
• The traditional approach of initial medical treatment after diagnosis and shifting to
interventional treatment in case of breakthrough infections and new scar formation
needs to be challenged, because the treatment should be tailored to different risk
groups.
• Surgical correction should be considered in patients with persistent high-grade reflux
(grades IV/V). There is no consensus about the timing and type of surgical correction.
The outcome of open surgical correction is better than endoscopic correction for
higher grades of reflux, whereas satisfactory results can be achieved by
• endoscopic injection for lower grades.
• The choice of management depends on the presence of renal scars, clinical course,
grade of reflux, ipsilateral renal function, bilaterality, bladder function, associated
anomalies of the urinary tract, age, compliance, and parental preference.
• Febrile UTI, high-grade reflux, bilaterality, and cortical abnormalities are considered
to be risk factors for possible renal damage.
• The presence of LUTD is an additional risk factor for new scars.
Vesicoureteric reflux
Acute scrotum
• Symptomps:
– suddenly evolving
– scrotal / inguinal pain
– hyperaemia of scrotum
– swelling
– unilateral
– fever
– pyuria
• Diagnosis:
- phyisical examination
(abnormal (horizontal) position of the testis)
- ultrasonography + Doppler
(63.6-100% sensitivity, 97-100% specificity)
Acute scrotum
• torsion of the testis
– newborn – adolescent
– supra- or infravaginal
– requires prompt surgical treatment
Acute scrotum
Torsion - detorsion of the testis
Torsion of the appendix testis
Thank you for your attention!